Healthcare from the perspective of a clinician encompassing both the capture of the clinical viewpoint as well as the technology to help clinicians capture knowledge at the point of care
The thoughts expressed are my own and do not necessarily represent those of Nuance

Monday, December 17, 2012

If a lab test shows high cholesterol, Folch is quick to call or email. No patient can leave the office without scheduling an annual eye exam, a key preventive test. A missed exam or an appointment leads to another call.

"We are a real pain in their necks," joked Folch, a primary care physician in suburban Boston. "We track them down."

That kind of attention has always been good medicine. For Folch, 59, it's now good business. He is among thousands of physicians in Massachusetts whose pay depends on how their patients fare, not just on how many times they see them. If patients stay healthy and avoid costly medical care, he gets more money.

This simple shift in how healthcare is paid for — long seen as key to taming costs — has been occurring in pockets of the country. But nowhere is it happening more systematically than in Massachusetts, the state that blazed a trail in 2006 by guaranteeing its residents health insurance. Now Massachusetts, a model for President Obama's 2010 national healthcare law, may offer another template for national leaders looking to control health spending.

"There have been few greater periods of change in American medical history … and this is the epicenter," said Dr. Kevin Tabb, a former chief medical officer at Stanford Hospital and Clinics in Northern California who now heads Beth Israel Deaconess Medical Center, one of Boston's leading hospitals. "It is striking how different Massachusetts is from the rest of the nation."

In the last three years, commercial insurers in the state have moved nearly 1 million patients into health plans that reward doctors and hospitals that control costs while improving quality.

About 180,000 Massachusetts seniors are on track to get care from physicians paid this way by Medicare through a new initiative included in the national health law. And this summer, state lawmakers passed legislation aimed at moving 1.7 million government employees and Medicaid recipients into similar health plans.

Within a few years, close to half of the state's 6.5 million residents could be in a health plan that pays for medical care in a fundamentally different way.

Massachusetts' move to reshape how healthcare is financed is still in its infancy. And the state continues to have the nation's highest medical costs, spending nearly 50% more per person than the national average.

That has fueled skepticism from conservatives who see too much government involvement and from liberals who say the state should more aggressively set medical prices. "I don't see how we can rely on market forces," said Nancy Turnbull, associate dean of the Harvard School of Public Health.

But early research in Massachusetts suggests the approach may be slowing health spending. And medical providers, business leaders and elected officials are increasingly hopeful they are making headway.

"Whether this is sustainable remains to be seen," said James Roosevelt Jr., president of Tufts Health Plan, one of the state's largest insurers. "But there is a broad consensus that it makes more sense to pay for healthcare this way."

The building block of the Massachusetts experiment is a contract between insurers and groups of doctors known as a global payment. In such contracts, physicians receive a budget to care for a cohort of patients. If doctors can care for their patients more economically, they keep a portion of the savings. If patient care exceeds the budget, they pay a penalty.

That is supposed to encourage physicians to keep their patients healthier and direct them to lower-cost hospitals and specialists.

If poorly designed, the arrangement can create a financial incentive to skimp on care. That perceived problem undermined earlier experiments with global payments and provoked a backlash against managed care in the 1990s.

"The most widespread attempts to do this failed," acknowledged Andrew Dreyfus, president of Blue Cross Blue Shield of Massachusetts, the state's largest health plan and a leading proponent of the new generation of global payment contracts. "There was no quality measurement.... It was really just about dollars."

In a key change, Blue Cross now links its contracts to dozens of quality metrics that track whether patients get the right screenings and exams, whether doctors and hospitals prescribe the correct drugs — even whether patients are satisfied with their care. That means a doctor who withholds care in hopes of saving money faces a penalty if patients suffer or are unhappy.

In Folch's suite outside Boston, these measurements have been transformational.

On a shelf in his tidy office are reams of spreadsheets, updated constantly, that outline how each of his patients is faring, which tests they have taken and which are due. With bonus payments from Blue Cross, he has hired new aides and installed a new computer system to better track his patients.

"We had to change the way we practiced," Folch said.

Folch also had to explain to patients why he wants them to get X-rays, eye exams and other routine care at the community hospital rather than at one of Boston's famous teaching hospitals, where an MRI that normally runs about $1,100 can cost as much as $1,650.

That wasn't easy.

"I try to explain that I'm not throwing them to the lions. I am referring them to people that I go to," Folch said. "If you have some rare form of cancer, then of course we're going to, say, get a second opinion.... But I had a lot of difficult conversations at first."

Some patients quit his practice.

Change has not come easily around the state, particularly for hospitals that depend on filling beds, not on keeping patients healthy enough to prevent hospitalizations.

Medical practices like Folch's are already making significant strides, however.

Between 2008 and 2011, the percentage of Folch's patients getting recommended colorectal cancer screenings increased from 61% to 82%. The share of patients with cardiovascular conditions managing their cholesterol jumped from 75% to 89%. And last year, all of Folch's diabetic patients successfully managed their cholesterol and had their yearly diabetic eye exams.

"If he sees something he doesn't like, he contacts me right away," said Bill Wooster, a 59-year-old sales representative who began seeing Folch after having a stroke four years ago. "I'm his patient, but I feel like more of a friend."

Those results are mirrored elsewhere. Statewide, the quality of care provided by physicians in a Blue Cross contract like Folch's — known as an Alternative Quality Contract — outpaced that of other medical providers, according to an analysis by Harvard Medical School researchers published in the journal Health Affairs.

Although the cost savings were modest, healthcare spending increased more slowly for the Blue Cross medical practices compared with others. Patients were hospitalized less and used fewer expensive services like advanced imaging. "These results suggest that global budgets with pay-for-performance can begin to slow underlying growth in medical spending while improving quality of care," the researchers concluded.

It's unclear whether other states, especially those where political resistance to the national health law remains fervent, will follow Massachusetts' lead on cost control. "Much of the rest of the country is still battling over the merits of covering everybody," said Alan Weil, president of the National Academy for State Health Policy.

In Massachusetts, however, the reforms remain very popular. "This has allowed me to be a better doctor," Folch said. "And it's better for my patients."

This seems like a really simple and a great strategy - it would help to capture data in sufficient detail to be able to demonstrate value and quality in the population. The capture of this data would be secondary to the actual health management and delivery of care that is keeping patients well. Unlike the current system which focuses on the documentation as verification of clinical activity and consumes much of the doctors time. I'm willing to bet most clinicians would be supportive of any system that focuses on the care and generates sufficient information to demonstrate the health improvement rather than burdening the care providers with data entry tasks.

Wednesday, December 12, 2012

Here's my list of 12 things coming to Healthcare in the next 12 months

Tablets - in particular the iPad Mini which has captured the imagination and is ready for prime time in a perfect balance fo form factor

Voice Enablement - it's everywhere and quite right too but expect it to get a whole lot better as medical intelligence comes to the voice interface

ICD10 solutions that don't crush your clinicians and require them to become data entry clerks - the technology is here to provide tools to deal with all the data requirements on the back end

Data Analytics and Big Data - we are only scraping the surface of this area but as we get more data and understand more expect more tools and discoveries to emerge

Home Healthcare Management - the medical home is playing an ever larger part in the care and management of patients and tools and technology will expand past the current set fo home health devices and be better connected and integrated into the care system

Patient engagement - still in its infancy but we have seen a major push towards patient engagement and enablement

Mobile Health - we've seen the FDA move quicker than ever to license the AliveCor ECG application and expect this trend to accelerate with more tools and devices emerging

Social Media - almost did not put that in here since it has been exploded onto the scene but that trend is only going to continue

Security - with the expanding connectivity comes all the associated risks and expect major failures in securing of clinical data to hit the headlines

Technology - will increasingly impact healthcare with more pervasive use throughout the system, not all of it will work well but it will become part of most practices

Interoperability - I expect we will still be waiting for true open sharing of data and that won't come until the incentive model changes are fixed to encourage sharing of information..in the intervening time patients will become the biggest drivers pushing for interoperable medical data

Customized Medicine; Genotype and Phenotype - increasingly available, better understood and now been applied in more and more areas - we've seen the emergence of mobile apps to help analyze your genome and now seeing the analysis applied to the MicroBiome - expect to hear much more about this

Monday, December 10, 2012

This article helps detail some of the new findings emerging relative to the effects of the Microbiome and perhaps start to explain the significant differences found in populations based on where they grow up. In a controversial claim from the Irish study

the study also suggests that this microbial make-up is driven by a diet high in fat and lacking in fibre, and that a decline in our microbial community underlies ill health as we grow old

This does run back to the challenge of correlation vs causation but there is a suggestion that altering your microbiome can ave significant positive effects...unfortunately we don't know how:

We just don't have a very good idea yet of the specific parameters that could set the microbiota in a good direction versus a bad direction

It puts an interesting perspective on the increasing incidence of cesarean deliveries which remove the exposure of the infants first exposure to the microorganisms that would have occurred as they passed through the birth canal. The current study focusing on the "Mediterranean" diet will offer not only insights into the value proposition that people from those areas seem to have benefitted from a longer healthier life with a diet rich in olive oil, fish and fresh vegetables but perhaps help explain this effect

“First person who sees this message and calls me wins $20” buried in the body of an email

Partial information distorted by least knowledgeable staff member delivered at most disruptive time

Probability theory – Which is more likely?

Team based urologists

Internists who cut to the chase

ED docs who read the information before the meeting

CIOs who “get it” with plenty of budget

Social networking - which environment is most dangerous for CMIOs?

Physicians lounge during a documentation rollout

Surgeon’s Christmas party at last call

Nursing dept meeting after volunteering them to pick up a few more tasks

Facebook after you’ve had a few drinks and a tough week

True or False – if you aren’t confused, you don’t know what is going on

True

False

Futures – After the singularity, how will you change a lightbulb?

Answer – You don’t change lightbulbs that are smarter than you

Quality measures – As CMIO, you have been asked to redefine all workflows for new quality measures, ensure physician input/acceptance/compliance, and implement within a month across a four hospital system? What is the best approach?

Do nothing – another list of measures will be out in a month.

Simply declare salaries will be attached to the metrics, and announce it on twitter.

Spend weekends doing flowcharts, spreadsheets, and education materials, only to find no one comes to dept meetings, they won’t read emails, and their office manager dumps all snail mail directly in trash

Friday, November 30, 2012

Dr Tornado's recent post on "How I met your EMR" takes a lighter look at the challenges of EMR use in healthcare and specifically makes the point that:

the goal of human-machine interaction engineering is to produce a user interface which makes it easy, efficient, and enjoyable to operate a machine in the way which produces the desired result. This generally means that the operator needs to provide minimal input to achieve the desired output, and also that the machine minimizes undesired outputs to the human.

But it is the visual that brings it home:

While the makes light of the problem the point is serious - there is a list of LE-GEN-DA-RY suggestions - don't overload the screen or the user, make it quick, easy and *fun* to use.

He qualified this by saying that if it offered some value to him and the patient then it could be acceptable(for instance making sure he carried out a clinical action that had been missed). In far too many cases these systems and processes just demand extra work for little benefit to the clinician. Focusing on capturing data for the wrong reasons is at the root of this problem - if we are trying to capture data for the purposes of billing, reporting on quality or other analytics tasks then that will be the focus. But clinicians want to focus on the patient and the care they deliver - and it was an interesting concept in this article The future state of clinical data capture and documentation: a report from AMIA’s 2011 Policy Meeting that covered AMIA's 2011 Health policy meeting that included the shortcomings that are well documented:

They highlighted the shortcomings of current approaches that impede efficient data capture and presentation, fall short of accurately representing clinicians’ thinking, and fail to accommodate clinical workflow

But it was some of the potential solutions that were interesting:

Stetson et al noted that documents are created for many different purposes and their value and quality may be assessed using different metrics that may not be compatible. For example, a note might be written to inform a colleague about the clinical status of a patient without concern that it generates a ‘comprehensive bill’. Thus, it might be deemed of high value with respect to clinical communication but poorly compliant and not supportive of billing or utilization review or clinical quality measures.

There is a desire to codify data and that can be achieved using natural language processing. So perhaps offering tools that allow clinicians to capture the note in the way we were trained to do: to inform our colleagues on the clinical status and the medical decision making. This can be done through any means suited to the clinicians - per Doc Tornado

Article 5 - A bro EMR lets bros create, edit and sign off notes using any input method, any device and a combination of them.

And then use technology like Clinical Language Understanding to extract out the medical intelligence and offer feedback to help capture all the pieces necessary for the other purposes (clinical quality measures, billing, clinical management) with minimal interruption in the workflow but significant added value?

Thursday, November 29, 2012

A Nurse Learns Firsthand That You May Fend For Yourself After A Hospital Stay

1Beth Ann Swan (bethannswan@gmail.com) is dean and professor at the Jefferson School of Nursing at Thomas Jefferson University, in Philadelphia, Pennsylvania. She and her husband, Eric, express their gratitude to their colleagues and the many great health care professionals who supported them after Eric’s stroke.

At 9:45 on the evening of Tuesday, April 26, 2011, the phone rang in our home in suburban Philadelphia. When I answered, I heard the voice of my husband Eric’s colleague, who was with him in Chicago on a business trip. They wouldn’t be flying home that evening, he told me.

Had they missed the plane? “Not exactly,” he answered. Eric was in the emergency department of a hospital near O’Hare International Airport. He had collapsed while boarding the plane to Philadelphia.

In an instant, we were thrown into the unreal world of medical “care coordination” and “transition management.” There would be no easy way for us to get Eric from a hospital there to a hospital here and then to home. And along the way there would be gaps in the care Eric received—gaps so large they were more like chasms. We just didn’t know it yet.

Chicago

What had felled Eric was a brain stem stroke, which had caused what is known as Wallenberg’s syndrome. The stroke had blocked an artery on the right side of his neck, depriving part of his brain of the blood it needed. A formerly healthy fifty-three-year-old male, Eric now was far from home, hospitalized with a serious stroke.

My thoughts were racing. Thank goodness he wasn’t alone, thank goodness the stroke happened before the plane took off, and thank goodness I’m a registered nurse who works at a world-renowned academic health center where I have friends and resources.

My first call was to the president of the academic health center in Philadelphia where I work, who is himself a neurologist. He immediately started working to get Eric into the best stroke center in Chicago. Next I called my mother to come stay with Eric’s and my thirteen-year-old daughter. By midnight I was running around the house packing a suitcase, with no idea how long we’d be in Chicago.

The next morning I left the house at 5:00 to fly to Chicago. I cried all the way to the airport. How was I going to get Eric transferred from the community hospital where he was at that moment to the Chicago academic health center with specialized stroke care, and then get him home?

I arrived at Eric’s bedside at 11:30 a.m. on April 27. Although a bed was waiting for him at the stroke center, it took me until 5:30 p.m. to get Eric into a hired ambulance. By 6:30 p.m. he was in the neurologic intensive care unit at the Chicago academic health center. As his wife, I wanted to cry. Instead I put on a brave face and became his care manager.

Eric spent ten days hospitalized in Chicago. He couldn’t swallow, and he couldn’t walk. He had rapid, involuntary eye movements, called rotary nystagmus, that made him look like a cartoon character with his eyeballs going round and round in circles. He also had a drooping right eyelid; pupils that were different sizes; double vision; numbness on the right side of his face and in his left arm and leg; and other neurologic issues.

What Went Well, What Didn’t

During Eric’s ten-day hospitalization, he was cared for by a team of more than fifty health care professionals and students. He was asked to repeat his story over and over, and although information was passed along from shift to shift, like the whispered game of telephone, inaccuracies inevitably cropped up. It was up to him, as the patient—with my help—to correct them.

Eric also experienced a series of micro transitions in Chicago, as he moved from the neurologic intensive care unit to the step-down unit, and then to the general care unit. Thankfully, during these internal transitions, communication and handoffs went smoothly.

But the later macro transition from the academic health center in Chicago to an acute rehabilitation hospital in Philadelphia was challenging. There was no communication about the handoff between the two facilities; neither had a system to handle this type of complicated transfer. I don’t know why, given that such situations are hardly unique. But everything was left to us, the ill patient and his wife. Basically Eric was going from a group of fifty caregivers to one—me—to handle his interstate transfer.

My first challenge was getting a copy of Eric’s complete health record from his hospitalizations in Chicago, along with copies of all of his imaging studies. It took many conversations and phone calls until I was finally given paper records to carry back to Philadelphia by hand. Who knows if electronic health records might have been a possibility?

My second challenge was to locate an acute rehab unit bed in a hospital that would be available on the day and at the time when Eric needed it, with the timing a moving target.

My third challenge was to get approval from our health insurance company to transfer Eric from a hospital bed in Chicago to an acute rehab hospital bed in Philadelphia.

From the moment Eric fell ill, the goal was to get him hospitalized back home in Philadelphia. Even so, a social worker first met with us to discuss planning for Eric’s discharge only five days before he was transferred.

The transfer process would have difficulties, especially because Eric couldn’t walk. At about $10,000, hiring an air ambulance was prohibitively expensive. To fly on a commercial airline, Eric would need to be able to transfer himself with assistance from a wheelchair to an airplane seat.

In addition, managing this city-to-city transition would require complex care coordination and transition management on our part, as well as tenacity and the micromanagement of dozens of details. How, I wondered, do others in similar circumstances—especially people without my nursing knowledge, familiarity with hospitals, and professional contacts and resources—navigate this kind of complexity?

At 1:15 p.m. on May 6, Eric and I flew out of Chicago. We had copies of Eric’s health records, which included a hospital discharge summary, the list of medications he was taking at the time he was discharged, and his imaging studies. This hand-off consisted of an envelope given to us by a resident physician.

We arrived in Philadelphia at 4:15 p.m., where we were met by an ambulance I’d arranged for through my work contacts. The ambulance transported Eric to the acute rehabilitation hospital, which we reached at 5:30 p.m. No one in Chicago ever contacted us to see if Eric had made it safely to the rehab hospital.

The Shock Of Rehab To Home

Eric continued to improve during the next twelve days. With intensive physical therapy, occupational therapy, and a variety of other therapies, he progressed from a wheelchair to walking with a walker, and then to being able to go up and down stairs. Although he continued to have double vision and problems with balance, coordination, and a constellation of other symptoms, on May 17 Eric was ready to go home.

Everyone was thrilled. But neither Eric nor I was prepared for what lay ahead.

As we soon discovered, I would be managing the care he would receive from six or more primary and specialty health care providers and services, as well as coordinating Eric’s various care needs at home. Keeping everything straight would prove to be a herculean task that required determination and persistence, to say nothing of the ability to navigate the after-hospital world filled with lengthy to-do lists. I would frequently find myself talking to answering machines, not getting callbacks, and yearning for answers from a human being.

This next, extremely complex home phase began when we were handed a ten-page report with Eric’s rehabilitation discharge instructions. The report listed the five medical personnel with whom Eric had to have appointments: a physical therapist, whom he was to see as soon as possible; a neurologist, a primary care doctor, and a vascular physician, all of whom needed to be seen within two weeks; and a rehab physician, to be seen within three weeks.

Because Eric was taking a blood thinner, he was required to have his blood drawn weekly; the first draw would need to be the next day, May 18. But the report didn’t say where to go or with whom to make the appointment.

Eric also was given seven prescriptions, along with twenty-nine pages of printed information about them; five pages of instructions dealing with home safety; six pages listing outpatient rehab facilities; and a handwritten list of four community stroke support groups. And his vision was still compromised!

Although the discharge instructions were written in lay terms, there was just too much information to absorb. No one reviewed it with us to be sure we understood it all—or at least the key points. Nor was there any communication with Eric’s longtime primary care doctor.

Just as when we’d left Chicago, there seemed to be an assumption that we could manage the complexities of Eric’s care on our own. No one assessed our readiness or capacity to do so, no one offered us any support, and we received no follow-up calls in the subsequent days.

Arrghh!

May 17 was a wonderful day—Eric was home at last. But it was also the day we entered the Twilight Zone.

When we arrived home, we found a voice-mail message telling us that we were “being placed in collection” for not paying a bill in the amount of $23,312 owed to the community hospital in Chicago where Eric had spent twenty hours. The mail box was jammed with hospital and ambulance bills. How, I wondered, can we reengineer the delivery of health care so that it is as timely and efficient as the medical billing process?

The next day, May 18, our new aggravations continued as we tried to find a lab to draw Eric’s blood that day and then to schedule his follow-up appointments. What about the neurologist appointment required in two weeks? The next available appointment was in October. The vascular physician appointment needed in two weeks? The next available appointment was in July. I started calling on members of my professional network to get appointments for Eric within the prescribed time frames.

Each office where we scheduled an appointment asked that we bring all of Eric’s Chicago records and imaging studies. This was another problem. We’d given all of that information to the rehab hospital here in Philadelphia—and it had lost everything. I needed, again, to gather all of the records and imaging studies from Chicago.

And that phone call saying we had an unpaid balance of $23,312 in Chicago? After making multiple calls, I discovered that the community hospital had incorrectly recorded Eric as having Medicare Part A and no other insurance. But the hospital informed me that its error was our problem. It would take at least thirty days to correct the bill, and in the meantime the hospital said it couldn’t reverse the collection notice. We continued receiving calls to our home. The calls stopped on June 23 when the matter was finally resolved; in fact, we owed just $3,076.

Looking Back

My most striking discovery during the year following Eric’s hospital and rehab stays was that his outpatient care involved no registered nurses. While he was in a hospital, if I had a question about anything, I had 24/7 access to one of Eric’s registered nurses. Yet the help we needed in navigating the outpatient setting was as intensive as the care that registered nurses had delivered during his hospitalizations.

After he was discharged, we were on our own. Yet not a day went by when we weren’t performing some activity that dealt with coordinating care and managing transitions among all of Eric’s doctors and other providers. We had no identified point of contact, no phone number, no e-mail address to use for support or guidance. No one was knowledgeable about Eric’s comprehensive care plan, and no one had or provided expertise in coordinating his still-complicated care once he was home.

As a patient’s wife, I would have welcomed having an RN as a point of contact. As a nursing school dean, I know the evidence demonstrating that registered nurses are critical to the operational and financial success of health care delivery systems. Their education, knowledge, skills, and competencies are as much an asset in outpatient settings as they are in hospitals.

I also know that nurses have the expertise to bridge care transitions and are critical to coordinating care across all settings. The Care Transitions Intervention developed by Eric Coleman at the University of Colorado uses “transitions coaches,” primarily nurses and social workers, who first meet patients in the hospital and then follow up through home visits and phone calls. Another proven transitional care model, developed by Mary Naylor and colleagues at the University of Pennsylvania, employs advanced practice nurses to coach patients and their caregivers, coordinate follow-up care plans, and provide regular home visits and round-the-clock support by phone.

Although these models have been adopted by hundreds of hospitals, it is frustrating that they aren’t more widely utilized. Fortunately, one of the reform strategies in the Affordable Care Act, the formation of accountable care organizations, should spur health systems to adopt these models and other techniques to better manage posthospital transitions and care management. Accountable care organizations are expected to deliver coordinated, efficient, and effective care by accepting responsibility for the cost and quality of care delivered by a group of providers.

The wheels are already in motion. As it stands now, the Centers for Medicare and Medicaid Services has established thirty-three quality measures for accountable care organizations, some of which deal with the patient-caregiver experience. The data to construct the measures are already being collected in a survey, the Consumer Assessment of Healthcare Providers and Systems, conducted by the Agency for Healthcare Research and Quality.

But will these measures go far enough to capture the actual, full experience? I hope information is available on the details. For example, the patient-caregiver experience is a broad measure that includes how well doctors communicate; it implies a verbal exchange or discussion of information. In our case, technically, we were “communicated with,” but the communication was far from adequate.

Providing patients with written instructions before they’re discharged from a hospital might be considered a type of handoff, but it’s not a measure of patient care being coordinated or of a patient’s transition being managed. That’s especially true when there’s no attempt to be sure that the patient and family understand how to follow up properly on the care instructions.

For years, numerous national reports have called for patient-centered care, yet health care organizations haven’t achieved measurable or sustainable change in that area. A 2011 Institute of Medicine report, The Future of Nursing: Leading Change, Advancing Health, also called for care that is centered on the patient and further recommended reconsidering the roles of health professionals, including registered nurses, to transform current practices dealing with care coordination and transition management.

True coordination and management are made up of dynamic processes requiring ongoing communication between patient and provider and among multiple providers. Patients and their families need to participate actively in these processes at all stages, including needing to know what to do if conditions worsen when they are home.

Looking Ahead

Patient-centered care has to be more than a trendy phrase. Experiences such as my family’s offer real-world guidance on what’s needed to get it right.

We need to ensure that patient-centered care is understood to be a long-term relationship in which patients have a specific point of contact with their team of providers. That team member must be accountable to those patients and responsible for coordinating their care. There must be contingency plans making clear who patients are to get in touch with when their identified point of contact isn’t available.

Additionally, patients and their families need access to information around the clock. This could be accomplished in small practices with a designated on-call provider who has access to the practices’ electronic health records, or by call centers staffed by registered nurses with access to the records.

We need to acknowledge that true patient-centered, team-based care coordination covers all of a patient’s micro and macro care transitions, all parts of the hospital setting, and the move from hospital to home.

At the heart of this coordination is assessing patients’ and families’ readiness to manage their care and their capability to do so. We should never assume that they can do it all on their own.

When people are in hospitals, they’re sick and vulnerable. That doesn’t necessarily change on the day they’re discharged. How can we expect not-yet-well people to suddenly begin managing all of the complex medical and personal issues that just the day before were being handled by an entire team of trained professionals?

We have to figure out a way to handle these patient transitions in a kind, sensible, thorough, and realistic way. Registered nurses seem to me like the group with the right training for the job, but I also believe that getting it done properly is more important than which profession does it. The bottom line: We need patient care and transition systems inside and outside of hospitals that work efficiently. Until they do, patients run the risk of falling into a terrible abyss of uncertainty as they go out the hospital door.

Great article from a Healthcare professional who struggled to navigate the system with her husband who suffered a stroke. But it was this comment that was worth repeating

How, I wondered, can we reengineer the delivery of health care so that it is as timely and efficient as the medical billing process?

How indeed - we can create efficient systems that throws out bills in quick fire fashion but are unable to produce an electronic version of a medical record that can be transferred easily to another care provider and system!

Monday, November 26, 2012

Dr Jones sends his patient John to the radiology department for an x-ray of his nasal bones. John’s pet turtle bit him and, distracted by the pain, John walked into the lamppost in the driveway of his mobile home, causing him to break his nose and develop a headache.1

In the coming world of ICD-10, we’ll actually have—perhaps unbelievably—several ICD-10 codes in play for a case such as this one: W59.21XA, Bitten by turtle, initial encounter; W22.02, Walked into lamppost; Y92.024, Driveway of mobile home as the place of occurrence of the external cause; S02.2, Fracture of nasal bones; and G44.311, Acute posttraumatic headache intractable.

The upcoming transition to ICD-10 on October 1, 2013, and the new electronic transactions standards for claims that go into effect on January 1, 2012, grew out of HIPAA. The law included provisions for the standardization of healthcare information, designating standards for transactions of medical information, including claims, eligibility, and referral authorizations. On January 1, 2012, the electronic transaction standard for claims submission will change from version 4010 to 5010. On an even larger scope, the 2013 conversion from ICD-9 codes to ICD-10 codes will dramatically change the revenue cycle for all healthcare institutions. Together, version 5010 and the ICD-10 code adoptions are the solution to standardized healthcare information for HIPAA compliance.

ICD-9 codes have been around for approximately 30 years, and version 4010 has been the electronic transmission standard since the inception of electronic claims. The ICD-9 codes are used in medical billing and are the diagnosis codes for a patient’s medical conditions. A typical code might be 782.3 for edema or 486 for pneumonia. ICD-9 is the official system used to assign codes to diagnosis procedures for patient treatment in all settings. The ICD-9 codes are three to five alphanumeric characters, and there are approximately 18,000 such codes in the system. The current ICD-9 codes present some challenges. Some use outdated and obsolete terminology, lack detail, are not applicable to today's practice of medicine, and do not fit in with the HIPAA provisions.

ICD-10 will be introduced with some significant differences from ICD-9 codes. There are two types of ICD-10 codes: ICD-10-CM and ICD-10-PCS. ICD-10-CM is the diagnosis classification developed by the Centers for Disease Control and Prevention for use in all U.S. healthcare treatment settings. These codes have three to seven alphanumerics and are very similar to the ICD-9 codes. There are approximately 68,000 of these codes. ICD-10-PCS is a procedure classification system developed by the Centers for Medicare & Medicaid Services (CMS) for only U.S. inpatient hospital settings. These codes use seven alphanumeric characters, and there are approximately 72,000 of these codes. Under ICD-9 when you see a given CPT code, you can usually identify the appropriate diagnostic code from a short list of candidates. With ICD-10 codes, this number of diagnostic codes increases by nearly tenfold.

Similarities and Differences There are some similarities and many differences between the old and the new diagnosis codes, including more characters and codes in the ICD-10 system. The main differences between ICD-9 and ICD-10 codes are shown in Figure 1.2

The CMS believes the change from ICD-9 to ICD-10 will bring improvements and benefits to patients, medical institutions, businesses, and the government. Some of the anticipated benefits are shown in Figure 2.2

ICD-10 codes were designed to be more specific than ICD-9 codes. The new codes will have details such as left or right body parts, the exact location of the condition, the activity during the initial or a subsequential encounter, and whether episodes are acute or chronic. For example, if someone fell on the ice while skating and suffered a concussion, the medical facility would have to report multiple ICD-10 codes for the occurrence: the concussion, the external cause (ice), the activity (skating), the location (where the ice rink is), and whether the injury was acute or chronic. Specific components incorporated into the new codes include the following:2

• laterality (left, right, bilateral);

• combination codes for certain conditions and common associated symptoms and manifestations;

• combination codes for poisonings and their associated external cause;

• obstetric codes identify trimester instead of episode of care;

• character “x” is used as a fifth character placeholder in certain six-character codes to allow for future expansion and to fill in other empty characters (eg, character 5 and/or 6) when a code that is less than six characters in length requires a seventh character;

• two types of Excludes notes: one for codes and one for conditions excluded;

• codes for postoperative complications have been expanded and a distinction made between intraoperative complications and postprocedural disorders.

With these new codes, the inventory of diagnosis codes will increase from 18,000 to 140,000. While there may have been one code for a particular occurrence in the ICD-9 list, there may be 10 or more ICD-10 codes. For example, in the old system, there was one code for angioplasty; in ICD-10, there are approximately 854 codes. In ICD-10, there are 195 codes for suturing an artery and 312 codes that involve animals, with 72 of those dealing with birds.2 Of the 140,000 new codes that will be available, some are unique and interesting, such as the following:

Impact on Radiology Radiologists depend on the referring physician to give the order for and the reason behind an exam. They are also dependent on the physician for pertinent information related to an ordered exam. With ICD-10 codes, the amount of information required from the referring physician increases dramatically. Imaging facilities will have to acquire a much greater history for a patient when scheduling an exam for the purposes of precertification, dictation, and subsequent billing of a procedure.

Secondly, radiologists must be much more specific and detailed in their documentation and wording of a completed exam. The coding of the dictation will depend on whether the patient is an inpatient or an outpatient, since ICD-10-PCS codes are only for inpatient procedures. Therefore, the same patient can have the same exam twice, one as an inpatient and one as an outpatient, and the report codes will not be equivocal. In the ICD-10-PCS codes, there are three sections devoted to radiology. Radiologists will need to pinpoint the areas being imaged and the type of imaging being performed.3

ICD-10-PCS codes for inpatients must be matched correctly with the CPT code for the procedure. For example, suppose a patient fell in a chicken coop, suffered significant head trauma, and was admitted to the hospital. The patient was then sent for an MRI of the brain. Under the current system, the billing department would use CPT code 70551 for an MRI of the brain without contrast. The matching ICD-10-PCS code is B030ZZZ, Magnetic Resonance Imaging (MRI) of Brain. It would also be necessary to match up codes for the diagnosis in the ICD-10-CM code list, including S06.0X1A, Concussion with loss of consciousness of 30 minutes or less, initial encounter, and Y92.72, Chicken coop as the place of occurrence of the external cause.

Failure to include the appropriate codes and detailed reporting will delay reimbursement and possibly cause a loss of revenue. The challenge for radiology providers will be preventing referring physician offices from inhibiting their work because the referrers are not ready for the new codes and reporting requirements. Imaging facility managers will need to work closely with referring physicians and help them prepare for the ICD-10 introduction on which radiology’s billing depends.

Getting Ready It is imperative that radiology providers start planning now for the October 2013 implementation. Facilities need to develop a strategic plan to make the conversion to the new system, perform training, and then test the training. Some suggestions for how to get ready include the following:

• Form a strategic business plan detailing the strategy to move to the future statement.

• Gain buy-in from management.

• Implement your strategy.

• Test, measure for successes and failures, and always improve.

A few other key points and suggestions:

• All personnel, systems, and functions in the radiology revenue cycle process should be involved in this process, from patient registration to delivering the radiology report to subsequent billing of the procedure.

• Identify challenges, including an understanding of the timeline associated with and implementation of the new codes, communication throughout your departments, IT, educating everyone in the department, and expected dysfunctions inherent to your institution.

• Develop education/training plans for all employees.

• Send radiology schedulers to medical coding classes or “boot camps” and require them to get certified in medical coding. It would be beneficial for your schedulers to know what information is needed when they schedule appointments and obtain detailed information at the first intake level.

• Work with referring physicians to make sure they are preparing for the ICD-10 transition and offer help to them.4

Final Thoughts Though October 1, 2013, may seem far away now, it will be here sooner than you think. Now is the time to prepare for potential coding challenges related to the changes, which will have huge implications on the radiology revenue cycle. There is much to lose in the way of revenue if a radiology department is not ready for the new codes. If you take the time now to properly prepare and train your employees for the changes, then you will be able to take advantage of the benefits of these new codes and not interrupt your business and the financial stream that supplies your institution.

ICD-9-CM Diagnosis Codes • Three to five characters • First character is numeric or alpha (E or V) • Characters 2 through 5 are numeric • A decimal is used after three characters

ICD-9-CM Procedure Codes • Three to five characters • All characters are numeric

ICD-10-CM Diagnosis Codes • Three to seven characters • Character 1 is alpha • Character 2 is numeric • Characters 3 through 7 are alpha or numeric • A decimal is used after three characters • Use of dummy placeholder “X” • Alpha characters are not case sensitive

Patients are moving in droves to online interactions and not just to access medical information online but also to interact with other people experiencing the same conditions or symptoms. But it is the opportunity for the positive social influence of people:

If you combine the capability of monitoring such things as blood pressure or glucose with social networking, then you can have managed competitions with your friends, your family, or your social networking cohort, and you can start to compete for such things as who has the best blood pressure or who has the best glucose level. This, of course, is beyond competitions as simple as who has the best weight or does the most activity in terms of number of steps

That is really exciting. I have had great positive experiences of this using a manual tracking system with colleagues for fitness and health monitoring and has now moved ingot he digital world in the form of FitBit tracking - you can see my FitBit Profile here. Sadly I lost my FitBit device (it fell off while I was running) about a month ago so the profile and activity is a little light but it is central to my constant focus on personal health management

Join me on Friday at 2:30 ET on VoiceoftheDoctorThere are three ways to tune in:

• Stream the show live – click the Listen Live Now to launch our Internet radio player.

• You can also call in. A few minutes before our show starts, call in the following number: Call: 1-559-546-1880; Enter participant code: 840521# • HealthcareNOWradio.com is now on iTunes Radio! Stream the show live – you’ll find this station listed under News/Talk

Historically we ran large scale trials that were blinded - in other words patients would either receive treatment or a placebo - neither they nor their treating clinicians would know which protocol they were on. At the end of the results the data would be analyzed and demonstrate either the positive benefit fo the treatment or not.

But what if giving the patient results in the death of patients - is it ethical to give a placebo when this results in the death of patents that could have benefitted from the treatment.

In the new style of trial we use surrogate markers for disease in a specific genetically similar group:

Researchers will be testing a drug that binds amyloid, a monoclonal antibody, in just [300][1] family members. They're not following these patients out to the point of where they get dementia. Instead, they are using surrogate markers to see whether or not the process of developing Alzheimer's can be blocked using this drug. This is an exciting way in which we can study treatments that can potentially prevent Alzheimer's in a very well-demarcated, very restricted population with a genetic defect, and then branch out to a much broader population of people who are at risk for Alzheimer's. These are the types of trials of the future and, in fact, it would be great if we could get rid of the randomization and the placebo-controlled era going forward.

Join me on Friday at 2:30 ET on VoiceoftheDoctorThere are three ways to tune in:

• Stream the show live – click the Listen Live Now to launch our Internet radio player.

• You can also call in. A few minutes before our show starts, call in the following number: Call: 1-559-546-1880; Enter participant code: 840521# • HealthcareNOWradio.com is now on iTunes Radio! Stream the show live – you’ll find this station listed under News/Talk

Wednesday, November 14, 2012

Welcome to this new series, Topol on The Creative Destruction of Medicine, which is named for my new book, The Creative Destruction of Medicine. I'm Dr. Eric Topol, Director of the Scripps Translational Science Institute and Editor-in-Chief of Medscape Genomic Medicine and theheart.org. In this series I will detail the driving forces behind what I believe is the biggest shakeup in the history of medicine.

What I'll be doing in these segments is outlining the parts of my book that represent the digital revolution occurring in the practice of medicine and how this revolution can radically improve the healthcare of the future. In this segment, I'd like to play the role of Dr. Gizmodo and show you many of the devices that I think are transforming medicine today. These devices represent an exciting opportunity as we move forward in the practice of medicine.

Let me just run through some of these. This is 2012, obviously, and this is something that we're going to build upon. You're used to wireless devices that can be used for fitness and health, but these are now breaking the medical sphere. One device you may have already noticed turns your smartphone into an electrocardiogram (ECG). The ECG adaptor comes in the form of a case that fits on the back of a smartphone or in a credit card-size version. Both contain 2 sensors. With the first model, you put the smartphone into the case and then pull up the app -- in this case I'm using the AliveCor app -- and put 2 fingers on each of the sensors to set up a circuit for the heart rhythm. Soon you'll see an ECG. What's great about this is you don't just get a cardiogram, which would be like a lead II equivalent; using the "credit card" version, you get all the V-leads across the chest as well. I have found this to be really helpful. It even helped me diagnose an anterior wall myocardial infarction in a passenger on a flight. It was supposed to be a nonstop flight, but, because of my diagnosis, it wound up stopping along the way. As an aside, after the passenger was taken off the plane to get reperfusion catheter-based therapy at a hospital, the pilots and flight attendants all wanted to have their cardiograms checked.

The second device I will show you is another adaptation of the smartphone, but this one is for measuring blood glucose. Obviously we do that now with finger-sticks, but the whole idea is to get away from finger-sticks. I'm wearing a sensor right now that can be worn on the arm. It also can be worn on the abdomen. What's nice about this is that I can just turn on my phone, and every minute I get an update of my blood glucose right on the opening screen of the phone. It's a really nice tool, because then I can look at the trends over the course of 3, 6, 12, or even 24 hours. It plays a big behavioral modification type of a role, because when you're looking at your phone, as you would be for checking email or surfing the Web, you also are integrating what you eat and your activity with how your glucose responds. This is going to be very helpful for patients -- not only those with diabetes, but also those who are at risk for diabetes, have metabolic syndrome, or are considered to be in the prediabetic state.

The third device I'd like to talk about is another device from the cardiovascular arena that comes in the form of an adhesive patch. It's called the iRhythm, and I tried this out on myself. It's really a neat device, because the results are sent by mail to the patient. You put it on your chest for 2 weeks, and then you mail it back. It's the Netflix equivalent of a cardiovascular exam. The company then sends the patient 2 weeks' worth of heart rhythm detection. I think it's a far better, practical way, as compared to the Holter monitor wireless device. It's not as time-continuous as the ECG or glucose device, but it's in that spectrum.

I want to now explain a fourth device, which I use on my iPad. This device allows physicians the ability to monitor patients in the intensive care unit on their iPads. I use it to monitor patients at the Scripps ICU. You can use it for any ICU that allows for the electronic transmission of data. Right now, I'm monitoring 4 patients simultaneously. You can change the field to monitor up to 8 patients simultaneously. This is a great way to monitor patients in the ICU because you can do it remotely and from anywhere in the world where you have access to the Web. This is just to give you a sense of what this innovative software sensor can do to change the face of medicine.

Finally, I wanted to describe is something that I've become reliant upon, and that's this high-resolution ultrasound device known as the Vscan. I use this in every patient to listen to their heart. In fact, I haven't used a stethoscope for over 2 years to listen to a patient's heart. What's really striking about this is that it's a real stethoscope. "Scope" means look into. "Steth" is the chest. And so now I carry this in my pocket, and it's just great. I still need a stethoscope for the lungs, but for the heart this is terrific. You just pop it open, put a little gel on the tip of the probe, and get a quick, complete readout with the patient looking on as well. I'm sharing their image on the Vscan while I'm acquiring it and it only takes about a minute. We validated its usefulness in an Annals of Internal Medicine paper, in July 2011,[1] describing how it compares favorably to the in-hospital ultrasound echo lab-type image. This could be another very useful device in emergency departments, where the wireless loops could be sent to a cardiologist. Another application it could be used for is detecting an abdominal aortic aneurysm. Paramedics who are out in the field, or at a trauma case, could use this to wirelessly send these video loops to get input from a radiologist or expertise from any physician for interpretation.

These are just a few of the gadgets that give you a feel for the innovative, transformative, and really radical changes that will be seen going forward in medicine. Thanks for watching this segment. We'll be back soon with more on The Creative Destruction of Medicine. Until next time, I'm Dr. Eric Topol.

I am excited to be talking with Dr Eric Topol on Friday and hope you will be able to join me. To help prepare you for the conversation and the breadth of areas that Dr Topol covers I am posting his vide presentations from Medscape that provide quick intros to different areas. This one looks at 5 devices that will change the future of Medicine.

Smartphone as an ECG

Stickless Glucometers for Continuous Monitoring

The NetFlix Cardiovascular exam - worn for 2 weeks and mailed for Review

Tuesday, November 6, 2012

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Earlier this year, well known cardiologist Eric Topol published his highly successful book, “The Creative Destruction of Medicine.” In it he describes several examples where smartphones, particularly the iPhone, have been morphed into first-rate medical devices with the potential to put clinical-level diagnostics in the hands of everyday users. Coincidentally, Topol was on a flight not long ago, returning from a lecture where he had spoken about a new device made by AliveCor. The pilot intoned an urgent, “is there a doctor on board?” In response, Topol took out the AliveCor prototype, recorded a highly accurate electrocardiogram (ECG) of an ailing passenger, and made a quick diagnosis from 35,000 feet.

As the leader in the smartphone revolution, the iPhone has been the platform of choice for early adopters in the health and quantified self arenas. Even so, there are a few shortcomings to development on the iPhone which, at least among DIYers, has led to Android becoming the path forward. Apple’s single-vendor solution and sequestering of many low-level input/output details behind the premise of ease of use have made interfacing the device to external sensors both a difficult and expensive proposition.

While it can be nearly impossible to write an Android app that will work on every device out there, writing an app to work on one’s own smartphone or tablet is fairly straightforward. Another challenge to the smartphone as a medical device is that many important sensor variables are analog in nature. It is possible to use the analog-to-digital converter on the audio input for data acquisition, however in the absence of sophisticated multiplexing one is limited to a single channel (unless some kind of expansion device is used).

Run tracking and calorie counting apps can certainly be regarded among the successes of the smartphone, but without dedicated sensor hardware, the philosophy of “there’s an app for that” only goes so far. A host of products now available for Android let users with a little bit of technical know-how create powerful devices previously found only in the domain of hospitals and law enforcement. One of the most successful expansion boards that allows Android devices to control external instruments and to orchestrate the collection of a variety of sensor data is the IOIO board. The system works well in wireless mode with most Bluetooth dongles, and its on-board FPGA gives 25 I/O channels, including plenty for analog input. It also handles analog output via pulse width modulation (PWM).

Vendors like Sparkfun, a popular supplier for the Arduino developer market, have realized the power inherent in readily programmable smartphones. They provide inexpensive heart monitors, as well as CO2 gas, dissolved oxygen, and blood alcohol content (BAC) sensors. These sellers provide documentation and, most importantly, access to the source code. With this information, interfacing with a BAC sensor, for example, is relatively straightforward and, if appropriately calibrated by the user, very accurate.

MK802 Android PC

USB stick computers running Android 4.0 (Ice Cream Sandwich) or newer, like the MK802, readily connect to boards like the IOIO, and can take the cost out of dedicating a phone or tablet to a sensor. They can log data to any of several storage mediums and cut a nice form factor when keyboards and displays are shed.

Despite the advances, a few ugly details in the smartphone-based health field are no longer capable of being ignored. The FDA will be increasingly faced with the task of deciding when a phone or tablet becomes a medical device that needs to be regulated as such, and when it is simply the front end for another device. Manufacturers of products for the seemingly straightforward task of monitoring glucose or insulin will have to tread carefully. Others seeking to enhance the absorption of medications through the skin by opening transient microchannels with current or ultrasound, perhaps built into a smartwatch, even more so.

In just a few years children wearing smart devices could become the norm. These gadgets could monitor variables like ambient peanut allergen using nanopore immunosensors with processing power to spare for forming dynamic early warning networks as conditions indicate. Without an efficient governance dispensing timely permission to use devices like the AlivecCor in humans, the initiation of life-saving care may too often begin with hardware designed and approved only for our pets. But if our regulatory structure organizes on the side of opening technological advancement, the future of these medical gadgets will be bright.

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The X-Prize amanged ot jump start the commercial space program and has taken the same principles to medicine offering $10 million to create a real world Star Trek Tricorder We are closer than you think

Monday, November 5, 2012

Dr Robert walker among a growing band of physicians finding benefit in dictating in front of his patients. As he puts it:

Before I started dictating in front of patients, I would have said I don’t make many mistakes. But now once or twice a week they correct me — they say it was their left knee, not their right, or that the accident happened two weeks ago, not last week. In that way, the patient verifies what’s going into their medical record, and it gives them ownership of it.

Speech brings efficiencies that saved the Army $3 Million but the process of creating the medical record in front of the patient brings additional quality control and greater detail in the medical record.

The tips to help successful adoption are good but I would include the primary requirement is good training and configuration

What a great post from Katie McCurdy on the new age of medicine and the fact that the medical record needs to be more than single points of data recorded when we stop by a healthcare facility or clinical office.

Katie comes at this as an interaction designer so is able to create a coherent and easy to digest record which might be harder for others. But as she rightly points out

a patient-generated timeline, if that artifact makes the storytelling process easier for the patient & more coherent for the doctor, it adds a lot of value even if the doctor doesn’t want to take time to carefully analyze it.

Agreed - and as many of the e-Patients have demonstrated capturing and understanding data is helpful in the successful management of their care. And importantly as Edward Tufte has demonstrated repeatedly clear presentation of data is the key to understanding.

Doctors may not have the time to assemble the record in these formats and while there is a challenge presentation of multiple formats the process of capturing and documenting alone is valuable and likely to lead better understanding for the patient and the clinical care team.

What a great resource to have an engaged e-Patient who has a background in interaction design working on a project like this.